Health Management Expert

Background 

We are looking for a health expert to join us in the tendering for a third-party monitoring assignment covering the delivery of lifesaving in-hospital care to vulnerable populations in Lebanon. The scope covers programmatic and financial implementation across a network of hospitals through desk review, hospital-based field verification, clinical audit, claims validation, and stakeholder engagement. 

Purpose of the Role 

The Health Management Expert designs and executes the clinical audit component of the verification exercise. The role establishes the audit criteria and instruments, conducts sample-based case review against those criteria, and produces documented, defensible findings on medical eligibility, clinical appropriateness, protocol adherence, and quality of care. The role is accountable for the audit trail behind every clinical finding reported. 

Key Responsibilities 

Audit design and instruments 

• Define clinical audit criteria and standards against which admitted cases will be assessed, drawing on programme protocols, national tariffs and guidelines, and evidence-based practice 
• Design case review templates, clinical checklists, scoring rubrics, and exception criteria during the inception phase 
• Contribute clinical logic to the sampling strategy for hospitals, cases, and claims, including risk-based and stratified selection of high-cost, high-complexity, or outlier cases 
• Define thresholds and escalation criteria for cases requiring second review or referral to the client 

Case review and clinical validation 

• Conduct structured, sample-based reviews of medical files, admission records, operative notes, and discharge summaries 
• Assess correctness and consistency of diagnosis, indication for admission, treatment provided, and length of stay against agreed audit criteria 
• Verify patient medical eligibility against programme criteria and referral pathways 
• Assess consistency between the clinical record and the corresponding claim and codified bill, and refer billing discrepancies for financial verification 
• Identify patterns of over-servicing, under-servicing, upcoding, unjustified admission, or unnecessary length of stay 
• Document each reviewed case with a traceable evidence trail linking the finding to source documentation 

Hospital-level field verification 

• Conduct structured on-site audits at sampled hospitals covering emergency, ward, and ICU admission practices 
• Verify implementation of clinical protocols, standard operating procedures, and service delivery standards 
• Assess quality of care delivered for lifesaving and limb-saving interventions 
• Verify adherence to non-discrimination principles across services 
• Assess continuity of care and referral mechanisms, including for patients found non-eligible 

Peer review and second opinion mechanisms 

• Audit whether peer review and second medical opinion mechanisms exist and operate as designed 
• Verify qualifications of specialists involved, adequacy of documentation, and adherence to referral criteria 

Findings and reporting 

• Conduct structured interviews with hospital administrators, clinical staff, and technical teams 
• Draft clinical audit findings for quarterly verification reports, ad-hoc verification notes, and the final consolidated report 
• Present findings and discrepancies in a form that withstands challenge from audited entities 
• Translate audit findings into prioritized, actionable corrective recommendations 
• Support closing meetings with hospital management and follow up on agreed corrective actions 

Required Qualifications 

Education 

• health-related degree from a recognized institution: Postgraduate qualification in public health, health systems, hospital management, or quality and patient safety  

Experience 

• Minimum 6-8 years of post-qualification experience, including substantial hospital-based clinical practice in Lebanon 
• Demonstrated hands-on experience in clinical audit, medical file review, utilization review, quality of care assessment, or medical claims review 
• Documented experience conducting audits or reviews where findings were formally reported to a third party such as a payer, insurer, regulator, or funder 
• Familiarity with Lebanese hospital operations, admission and discharge processes, and Ministry of Public Health service standards and tariffs 
• Experience with third-party monitoring, verification, or evaluation of health programmes is strongly preferred 
• Prior work with international organizations, humanitarian health programmes, or health financing mechanisms is an advantage 
• Experience in emergency, ICU, surgical, or trauma settings is an advantage given the lifesaving and limb-saving focus of the programme 

Technical skills 

• Ability to construct and apply explicit audit criteria and to justify clinical judgments in writing 
• Working knowledge of medical coding and codified billing structures 
• Competence with structured data collection tools and digital case review platforms 
• Strong analytical report writing in English, with the ability to present clinical findings to non-clinical audiences 

Languages 

• Full professional working proficiency in both English and Arabic is mandatory, written and spoken 

Competencies 

• Independence of judgment and willingness to document and defend adverse findings 
• Methodological discipline and attention to documentary detail 
• Diplomacy and professionalism when auditing clinical peers and hospital management 
• Ability to work to tight reporting deadlines across multiple sites simultaneously